Long-Term Care Facilities and Retirement Homes

The kit

The kit contains two sterile containers, a biohazard bag and requisition sheet. Please refer to the table below for details. 

Kit contains two sterile containers: 

The requisition

Please ensure that all the sections (1, 2, 4 & 5) of the requisition are completed. Any incomplete requestions will result in their rejection at the laboratory.
Take special care to ensure that the following sections and fields are filled out:

• Patient information section
• Public health unit outbreak number
• Date stool sample collected
• Date of symptom onset

The collection:

Before collecting:

• Verify the expiration dates on the sterile containers. DO NOT use expired kits, they will be rejected by the testing laboratory.
• If blood or mucous is found in the stool, take the sample from this part of the stool.
• Stool specimens that have been in contact with water in the toilet are unable to be accepted due to contamination.

When collecting:
*These first two steps are very important – if the label and/or form are missing information, illegible, or filled out incorrectly, the lab will not test the sample.

1. Fill out the label

• Label the sample containers with the individual’s name, date of birth, health card number (if known), and the date and time the stool sample was collected.

2. Complete the requisition

• Complete all of the required sections of the requisition (see the section on requisitions above).

3. Collect the stool sample

• Individuals who are independent: Defecate into a clean container (i.e., disposable plate, adult incontinence product, collector container).
• Individuals who require assistance/are incontinent: Collect the stool sample from the soiled adult incontinence product.
• Using the individual “scoop” attached to each of the caps, transfer the stool into the corresponding sterile containers. Fill the white cap container first.
• Fill to the line indicated on the container. Do not over fill.
• Tighten the caps. Do not use excessive force to tighten the caps as the containers may crack and leak. Samples that have leaked in transit will be rejected.
• Place the containers in the inner pocket of the plastic biohazard bag and seal it.
• Place the general test requisition form in the small outer pocket of the plastic biohazard bag. DO NOT place the form in the inner pocket.
• Place the biohazard bag into the brown paper bag and refrigerate the sample(s) immediately after collection. Stool samples should be placed on the bottom shelf of a fridge and food should not be stored in the same fridge as the stool samples. A cooler with ice or an ice pack can be used if a separate fridge is not available. DO NOT freeze the samples.
• Perform hand hygiene. If hands are visibly soiled, use soap and water.
• Complete the Facility Specimen Collection Request Form or call Ottawa Public Health at 613-580-2424 x 26325 for stool sample pick-up and delivery to the Public Health Laboratory located in Ottawa. Deadline for same day pick-up is 3:00 pm. DO NOT send with your regular lab courier.

Packaging and Transportation

• Ensure to include the completed specimen requisition forms for each specimen.
• Package the specimen to prevent leaking and use ice packs to maintain temperature.
• Clean and disinfectant cooler bag with a hospital grade disinfectant before and after delivery.  

It is important for staff to be advised upon hire about the influenza policy of the facility and/or their collective agreement, and the options available to them in the event of an influenza outbreak if they are not immunized.

When an influenza outbreak occurs, staff must obtain prescriptions for antiviral medication from their own health care provider and are responsible for their own antiviral-related expenses, unless they have coverage through a company or private health insurance plan. They are not eligible for prescription drug coverage under any circumstances from the Ontario Drug Program (ODP). Only under very specific circumstances, immunized health care workers may be eligible for reimbursement through the High Intensity Needs Fund (HINF).

During a laboratory-confirmed influenza outbreak, when the circulating strain is not well-matched by the vaccine, antiviral prophylaxis should be offered to all staff, regardless of vaccination status, until the outbreak is declared over, based on consultation with OPH.

Immunized Staff

Unimmunized Staff

• Unimmunized staff should be offered vaccine and take antiviral prophylaxis until immunity is reached or until the outbreak is declared over, whichever is shorter.
• Unimmunized staff who refuse to be immunized must take antiviral prophylaxis until the outbreak is declared over; staff may work with residents as soon as they start antiviral prophylaxis.
• Staff accepting to be immunized, but refusing antiviral medication, should NOT be permitted to work in the outbreak-affected area for a two-week period. Prior to being reassigned to another unit, they must be asymptomatic for 72 hours (3 days).

Prophylaxis

• During a laboratory-confirmed influenza outbreak, antiviral prophylaxis should be offered to all residents in the outbreak-affected area who are NOT already ill with influenza, regardless of immunization status, until the outbreak is declared over
• If respiratory symptoms develop in a resident while on prophylaxis, the dose should be switched to a treatment dose for five days. After five days, if influenza is not lab confirmed, the resident should return to the prophylactic dose until the end of the outbreak.

Treatment

Once an outbreak has been laboratory-confirmed as influenza, additional laboratory confirmation of new cases is not required to begin treatment of residents who meet case definition. It is important that:

• Antiviral treatment of ill residents who meet case definition is started as soon as possible, and within 48 hours of symptom onset
• Ill residents remain in their rooms for the duration of the antiviral treatment, which should be a total of five days

• If the resident meets case definition and has been symptomatic for MORE than 48 hours and antiviral treatment has NOT been started, use Appendix A for making decisions about the use of antivirals.
• If the outbreak is ongoing when the five-day treatment course ends AND the resident did NOT have lab-confirmed influenza (either the resident was never tested or had a negative influenza lab result) but was symptomatic, the resident should be switched to a prophylactic dose until the outbreak is declared over. This is recommended in case of a potential outbreak caused by more than one agent (see Appendix B).

• The new cases could be caused by another organism.
• There could be compliance/adherence issues.
• Resistance to the antiviral medications may have developed in the circulating strain.

In the event that the outbreak is not controlled with antiviral use:

• Consult with the OPH Outbreak Management team to determine if the antiviral agents should be continued.

Diagram 1: Influenza Outbreak antiviral treatment recommendations if treatment is not initiated within 48 hours of symptom onset

• Resident meets outbreak case definition
• Was antiviral treatment initiated within 48 hours of symptom onset? (NO)
• Is the resident clinically improving?
  • NO
    Provide antiviral treatment
  • YES
    Consider antiviral therapy for individuals in high risk groups*, or individuals with moderate, severe or complicated illness

* Note: please see AMMI Influenza guidelines (as current) for a definition of high-risk groups

Diagram 2: Influenza Outbreak antiviral prophylaxis recommendations for Line- listed cases after completion of treatment with antiviral medication

Is the outbreak still ongoing?

• NO
  No further action required
• YES

  • Are antivirals still being used for prophylaxis in residents on the line-listed residents' unit?

    • YES
      • Did the line-listed resident have laboratory confirmed influenza?
        • YES
          Do not provide prophylaxis. The resident would now have immunity to the influenza virus that is causing the outbreak.
        • NO
          Start on a prophylaxis dose until the outbreak is declared over.  This is a precaution in case there is an outbreak with more than one pathogen and the line-listed resident may have previously been infected with a non-influenza pathogen. 

References

• Hoffman-La Roche Limited, Tamiflu Product Monograph, Jan 2015
• AMMI  Canada  Guidelines,  Update  on  Influenza  Antiviral  Drug  Treatment  and  Prophylaxis for the 2015-2016 Influenza Season, 2016
• AMMI Canada Guidelines, Guidance for Practitioners on the Use of Antiviral Drugs to Control Influenza Outbreaks in Long-Term Care Facilities in Canada, 2014-2015 Season, 2015
• AMMI Canada Guidelines, The Use of Antiviral Drugs for Influenza: A Foundation Document for Practitioners, 2013
• Canadian Immunization Guide, Canadian Immunization Guide Chapter on Influenza and Statement on Seasonal Influenza Vaccine for 2016-2017, 2016
• Ministry of Health and Long-Term Care, A Guide to the Control of Respiratory Infection Outbreaks in Long-Term Care Homes, Nov 2015